General medicine case-06

August 24, 2022
Hello, I am p.aishwarya, a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

CASE SCENARIO:
CASE SHEET:
A 55 year old women came to casuality with cheif complaints of sudden loss of consciousness 30 minutes and  palpitation present and no chest pain no fever no sweating.

CHIEF COMPLAINTS:
Case of 
- sudden loss of consciousness 
- palpitation present 

HISTORY OF PRESENT ILLNESS:
Known case of :
diabetes mellitus since 2years (on glibenclamide)
Hypertension since 2years.
No tb, epilepsy,CAD.

ASSOCIATED DISEASES:

———
PAST HISTORY:

-not a known case of HTN/DM/Asthama/epilepsy.

PERSONAL HISTORY:
Normal appetite 
Regular Bowel movements. 
Has normal micturition with no burning sensation.
Has no known allergies.

FAMILY HISTORY:

Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancer.

GENERAL EXAMINATION:
Temperature: afebrile
Pulse rate : 60per  minute 
Respiratory rate : 20/min
B.p:160/90
Spo :99%
GRBS:34mg%
No pallor
No Icterus
No clubbing of fingers 
No cyanosis
No edema
MENSTRUAL HISTORY:
Menopause :

SYSTEMIC HISTORY:

CVS
S1 ,S2 present
No cardiac murmurs

RESPIRATORY SYSTEM:
Bronchial artery embolisation.

ABDOMEN:
 Abdomen-scaphoid
No tenderness
No palpable mass
No hernial orifices
No bruits
No free fluids
Bowel sounds heard
No palpable liver and spleen

CNS:
Patient is  unconscious.
No appreciable disease 

BIOCHEMICAL INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:
Hypoglycemia.

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